Pediatric Form (Ages 13-18)

Pediatric New Patient Intake Form

Ages 13-18

Is it ok to contact you at work?
Is this appointment related to an auto accident?

If this injury is related to an auto accident, please fill out the Auto Accident Questionnaire

Is your child receiving care from other health professionals?
How did the problem start?
Is this condition:
Has your child ever had a similar condition?
Has your child been treated for this problem before?
Does your child eat well?
Does your child have regular bowel/bladder movements?
Has your child ever been checked for vertebral subluxations?

Patient/Hospitalization/Surgical History

Any pets at home?
Any smokers at home?
Any night terrors, sleepwalking or difficulty sleeping?
Does your child have difficulty in school with attention or focus?
Do you know what Subluxation is?
Do any of your friends or relatives see a chiropractor?
If yes, do they use chiropractic for:
Are you seeking chiropractic for:
Does your child have a problem with acne?

Please mark off all areas of complaint on the diagrams

Draw over image
Please rate the intensity of your symptoms on a scale of 1-10 (1 being no symptoms, 10 being extreme)

Consent for Treatment of Minor

I hereby authorize Stromberg Chiropractic and any employee of Stromberg Chiropractic, to examine, x-ray and administer treatment as deemed medically necessary to my son/daughter named below.

Please select how minor treatments are authorized:

Protecting Your Health Information

New Regulation Passed

This new regulation is part of the Health Insurance Portability and Accountability Act or HIPAA and does three primary things:

  1. It helps standardize and simplify the way healthcare organizations exchange health care data.
  2. It provides consumers with additional protections for getting and maintaining health insurance coverage although, it does not guarantee coverage.
  3. It creates new security rules to ensure the safety and privacy of individual and medical records.

Our Pledge Regarding Medical Information

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive in our office. We need this record to provide you with quality care and to comply with certain legal requirements. In addition, we have a policy in effect that makes every attempt to maintain the confidentiality of all patients' information.

Disclosures of Medical Information

In addition to disclosing your medical information for treatment, payment and health care operations, we may disclose medical information for the following purposes: for a court order, subpoena, discovery request or other lawful process. We may disclose medical information to appropriate authorities if we reasonably believe that you are the victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose health information when authorized and necessary to comply with laws relating to worker's compensation, auto accidents, personal injury or other similar issues.

If someone calls or comes by, they will not be given any information about your care and/or appointments unless otherwise specified and noted in your file.

We will also be publicly noting your name in our newsletter and/or picture in our lobby unless otherwise specified. Upon becoming a patient, we will be entering your name and email into our database and you may receive our monthly newsletter. If you do not wish to receive our newsletters, please contact our office and advise the receptionist of such. This list will not be sold to any outside agencies.

Your Rights

You have the right to look at or get copies of your medical records and to receive a list of all the times we shared your medical information for purposes other than treatment, payment and health care operations.

Open Adjusting Concept

Because of the open adjusting concept in this office, it is possible for doctor/patient discussions to be overheard by other patients. Most discussions will involve spinal health, but may also include anything concerning the primary health care of that patient.

Notification by Mail or Phone

Patients may be contacted by mail, email or phone unless written notification is requested that contact be only in person.


If you feel that your rights have been violated, contact the Office Manager or the U.S. Department of Health and Human Services.

Cancellation Policy

If for any reason you're unable to make your scheduled appointment, please give us the courtesy of 24 hour notice. It is important that you reschedule your appointment. You may need to make up your visits on an additional day to get the results you want. When notice is not given, it causes scheduling problems for people who could have been seen.

If you cancel or reschedule your appointment with less that 24 hours notice, or overnight via phone, email or text, you will be charged a fee of $25.

If you No Call/No Show for your appointment and do not or can not make it up on the same day due to scheduling availability, you will be charged as shown below:

Chiropractic Visit: $60

Re-exam: $60

If you are charged a fee for Reschedule/Cancellations or for No Call/No Show, you will need to pay those fees before you can resume care.

This policy is not in effect to penalize patients, but only to help keep patient's care a priority. We should not take your health care more seriously than you do.

Thank you for taking the time to fill out this form.

Office Hours

Our Regular Schedule


9:00 am-12:00 pm

3:00 pm-7:00 pm


9:30 am-12:00 pm

2:00 pm-6:00 pm


9:00 am-12:00 pm

2:00 pm-6:00 pm


9:30 am-12:00 pm

2:00 pm-6:00 pm


9:00 am-12:00 pm

2:00 pm-5:00 pm






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